Disease management programs for hepatitis C - A team approach to setting goals

Hepatitis C is an important target for the development of disease managemen t programs. Hepatitis C virus (HCV) infection is common and most infected i ndividuals develop persistent infection. Although this is usually associate d with chronic liver injury (chronic hepatitis C), the infection and liver disease may be unrecognized for years. Most patients are relatively asympto matic and their illness remains clinically silent for at least 20 years aft er onset. In a substantial proportion of such individuals, the most widely available tests of the presence of liver injury, the serum aminotransferase s, may be persistently normal. If unrecognized and untreated, chronic hepat itis C may lead to unfavorable outcomes including cirrhosis, the complicati ons of end-stage liver disease, and hepatocellular carcinoma. These in turn sharply reduce health-related quality of life, lead to debilitating sympto ms, decrease life expectancy by increasing premature death, and result in v ery high costs of care including the most expensive form of treatment-liver transplantation. In fact, end-stage liver disease due to chronic hepatitis C is now the single most common indication for liver transplantation in th e US and Western Europe. Based on available data, the future illness and economic burden of chronic hepatitis C is likely to increase dramatically during the next few decades as currently infected, untreated individuals progress toward advanced liver disease. Unfortunately, treatment with the current agent of choice-the com bination of interferon alfa and ribavirin-is difficult, expensive, and effe ctive in only a proportion of patients. Nonetheless, computer-generated mod eling studies indicate that current treatment diminishes the reduction in l ife expectancy expected in chronic hepatitis C and that cost-effectiveness ratios either fall within the bounds of other widely accepted medical inter ventions or are cost saving. Disease management programs in hepatitis C need to be designed to reduce un healthy high risk behavior by education of the uninfected, promote health-s eeking behavior such as the avoidance of alcohol in those infected, institu te disease screening for those at risk with early confirmation of diagnosis , and initiate appropriate and effective treatment regimens, including acti ons designed to support adherence to treatment and appropriate follow-up. A dvances in treatment such as the development of long-acting pegylated inter ferons which may enhance response rates, may be effective in advanced disea se, and are well-tolerated should be incorporated into disease management p rograms when available. Disease management program design will require a mu ltidisciplinary team approach and careful assessment or the effectiveness o f these programs is needed.